Nurse Education Today 103 (2021) 104954

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Nurse Education Today

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Effects of case-based confusion assessment methods for intensive care unit

training on delirium knowledge and delirium assessment accuracy of
intensive care units: A quasi-experimental study☆
Young-Nam Kim, Dong-Hee Kim *
College of Nursing, Pusan National University, Yangsan-si, Republic of Korea

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Delirium evaluation is important because the development of delirium in critically ill patients
Assessment negatively affects their progress and prognosis. Although delirium assessment tools have been developed, nurses
Delirium have insufficient experience using these tools in clinical practice.
Education
Objectives: This study examined the effects of case-based confusion assessment methods for intensive care unit
Intensive care unit
Knowledge
education on delirium knowledge and assessment accuracy for intensive care nurses.
Nursing Design: This study adopted a pre- and post-test non-equivalent control group design.
Settings and Participants.
The study participants were 122 general nurses (61 participants each in the experimental and control groups)
working in the intensive care unit of one university hospital in South Korea.
Methods: Case-based confusion assessment methods for intensive care unit education comprised lectures on
delirium and confusion assessment methods for intensive care unit tools and delirium assessment education using
standardized patients. The experimental group received 80-min case-based confusion assessment methods for
intensive care unit training, whereas the control group received no intervention.
Results: Differences in the degree of pre- and post-knowledge in subcategories between the experimental and
control groups were the cause, symptom, and management. The delirium assessment accuracy score of the
experimental group changed from 2.89 ± 1.61 points before training to 8.11 ± 1.23 points after training,
whereas that of the control group changed from 2.92 ± 1.94 points before training to 3.05 ± 2.99 points after
training (Z = − 9.668, p < .001).
Conclusions: The case-based confusion assessment methods for intensive care unit educational program devel­
oped in this study is effective for improving delirium knowledge and delirium assessment accuracy in intensive
care nurses. Based on the study results, various cases can be developed for the education of intensive care nurses.

1. Introduction
Delirium refers to an acute change in consciousness, accompanied by
changes in cognitive and perceptual abilities (American Psychiatric
Association [APA], 2013). Delirium develops suddenly, and is typically
noted with changes in consciousness, widespread cognitive impairment
(affecting various factors, such as perception, behavior and mood,
ataxia, and incontinence), abnormal symptoms, and tremors (Brown and
Boyle, 2002; Ely et al., 2004; Inouye, 2006). The incidence of delirium
noted in past studies is as follows: Delirium was noted among 46 patients
out of a total of 250 patients (18.4%) in a study by Bilge et al. (2015),
among 22 patients out of a total of 99 patients (22.2%) in a study by
Limpawattana et al. (2016), among 69 patients out of a total of 149
patients (46.3%) in a study by Mori et al. (2016), and among 69 patients
out of a total of 149 patients (46.3%) in a study by Mori et al. (2016).
Based on a systematic review and meta-analysis, the incidence of
delirium was 5280 among a total of 16,595 (31.8%) patients admitted to
an intensive care unit (Salluh et al., 2015).
Delirium assessment accuracy is crucial because the development of
delirium in critically ill patients negatively affects patient progress and

☆
This study was approved by the Institutional Review Board of Pusan National University Hospital (H-1707-004-057).
* Corresponding author at: College of Nursing, Pusan National University, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do 50612, Republic of Korea.
E-mail address: dongheekim@pusan.ac.kr (D.-H. Kim).

https://doi.org/10.1016/j.nedt.2021.104954
Received 18 March 2020; Received in revised form 19 April 2021; Accepted 3 May 2021
Available online 14 May 2021
0260-6917/© 2021 Elsevier Ltd. All rights reserved.
Y.-N. Kim and D.-H. Kim
prognosis. Compared to patients without delirium, patients with
delirium had a significantly higher mortality rate during hospitalization
and a longer period of mechanical ventilation (Salluh et al., 2015).
Delirium may also lead to increased complications caused by accidental
extubation or catheter removal in patients, thereby resulting in a longer
stay in the ICU and increased morbidity and hospitalization (Boogaard
et al., 2012; Ely et al., 2004; Mori et al., 2016; Thomason et al., 2005;
Tilouche et al., 2018). To avoid the negative consequences of delirium,
efforts must be made toward the early detection of delirium through
regular monitoring using the appropriate diagnostic tools.
To ensure the early detection of delirium, the American Society of
Critical Care Medicine recommends that delirium assessments must be
conducted regularly for intensive care adult patients once per shift, by
using the delirium assessment tool (Barr et al., 2013). Confusion
assessment methods for the intensive care unit (CAM-ICU) is a reliable
tool for delirium assessment. The assessment process of the CAM-ICU is
simple and quick, and can be conducted on patients who experience
problems while speaking due to using ventilators (Ely et al., 2001c). In
addition, studies have shown 77%–100% sensitivity and 72%–100%
specificity (Ely et al., 2001b; Gusmao-Flores et al., 2012; Heo et al.,
2011). The CAM-ICU is a commonly recommended tool for delirium
assessment in ICUs in South Korea.
Although delirium assessment tools have been developed, nurses
have insufficient experience using them in clinical practice (Lee et al.,
2007). Approximately 85.2% of nurses working in an ICU had experi­
ence nursing patients with delirium, whereas only 7.7% of them had
experience using delirium assessment tools (Lee et al., 2007). Nurses
experienced low confidence using the assessment tool and interpreting
its results (Devlin et al., 2008; Ely et al., 2004; Gong et al., 2015; Inouye
et al., 2001). Education related to the use of these tools can help to
alleviate these problems, and patients with delirium can receive more
active care.
There are various educational methods, such as lectures, video
training, web-based training, and case-based training, for nurse educa­
tion. Case-based education is more comparable to lecture-based educa­
tion, in terms of knowledge (Kim and Jang, 2011) and nursing
performance (Kim and Jang, 2011; Jeong and Park, 2015), thereby
leading to improved adaptability in the clinic.
Most studies have examined factors related to nurses' knowledge of
delirium, recognition, and nursing performance (e.g., Van De Steeg
et al., 2015). Few studies (Blevins and DeGennaro, 2018; Detroyer et al.,
2016; Devlin et al., 2008; Gesin et al., 2012; Kang et al., 2017) have
highlighted the impact of education regarding the use of delirium
assessment tools on delirium knowledge and the ability of these tools to
assess delirium; these studies have focused on nurses working in ICUs.
However, these studies did not control for the time between imparting
education and conducting assessments. Hence, the participating nurses'
recollection of the information provided may have varied, or there may
be a limited number of experimental groups without any control group.
In the current study, we examined the effects of case-based CAM-ICU
education on delirium knowledge and delirium assessment accuracy for
nurses working in ICUs.
2. Methods
2.1. Study design
This study adopted a quasi-experimental design wherein a group of
test units performs a series of periodic measurements, followed by
processing. Moreover, another set of measurements was conducted in
this study to identify the effects of case-based CAM-ICU education on
delirium knowledge and delirium assessment accuracy for nurses
working in ICUs.
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Nurse Education Today 103 (2021) 104954
2.2. Participants, sampling, and sample size calculation
The study participants comprised 122 nurses working in the ICU of a
university hospital in South Korea. The inclusion criterion was regis­
tered nurses working in an ICU. The exclusion criteria were the unit
manager and nurses included as experts while developing educational
materials on delirium assessment accuracy in this study. The two groups
were divided according to the number of nurses working in the ICUs.
The first group comprised nurses working in the trauma ICU, whereas
the second group comprised nurses working in the medical, surgical, and
emergency ICU. A coin flip was used to determine whether these groups
would represent the experimental or control groups. The experimental
group consisted of nurses working in the trauma ICU. The control group
consisted of nurses working in the medical, surgical, and emergency
ICU.
The sample size of this study was calculated using the G-Power 3.1
program, and the number of samples was set to a one-sided test, which
was expected to improve the level of knowledge after the training based
on the t-test. When applied at 0.05, the number of participants were
calculated to be 51 in the experimental group as well as 51 participants
in the control group, with a total of 102 participants. A total of 122
participants (61 participants in the experimental group and 61 partici­
pants in the control group) were recruited, considering the dropout rate.
There was no dropout.
2.3. Data collection and ethical considerations
This study was approved by the institutional review board before
data collection. A researcher visited the nursing department in the
hospital and explained the study. Participation was voluntary, and
participants were informed of the purpose of the study and research
ethics, including confidentiality and anonymity. Participants were free
to withdraw from the study at any time, without any disadvantage to
their hospital records, and those who voluntarily provided written
informed consent were eligible for the study. The control group was
informed that after the study was completed, the desired participants
would be provided with the same training as the experimental group.
Data were collected between November 2017 and February 2018.
The questionnaire was distributed to each ICU in the nursing depart­
ment. After the questionnaire was completed, it was placed in an en­
velope to ensure anonymity of the survey data, sealed with a sticker by a
participant, and collected by the nursing department or research assis­
tants who did not participate in the intervention. The data collection
period of the control group was from November 1, 2017, to December
11, 2017, whereas that of the experimental group was from January 8,
2018, to February 9, 2018.
2.4. Instruments
Participants were requested to respond to a questionnaire regarding
their general characteristics, delirium knowledge and delirium assess­
ment accuracy.
2.4.1. Delirium knowledge
Delirium knowledge was used by Lee et al. (2007) to develop nurses'
delirium knowledge. This tool comprises a total of 45 questions: 10
questions related to delirium, 20 questions related to delirium symp­
toms, and 15 questions related to delirium management. For each
question, participants were requested to respond with either “yes,” “no,”
or “don't know.” Those who provided the correct answer were awarded
1 point, whereas an incorrect answer, or “don't know,” was awarded
0 points. The reliability of the tool at the time of development was 0.75
(KR-20) and 0.77 (KR-20) post development in this study.
2.4.2. Delirium assessment accuracy
We developed a delirium assessment accuracy tool to evaluate the
Y.-N. Kim and D.-H. Kim Nurse Education Today 103 (2021) 104954

accuracy of delirium assessments. The assessment tool comprised 10
cases and assessed whether each case of delirium was correctly assessed
using the CAM-ICU. The CAM-ICU comprised two stages. The first stage
was to determine whether delirium was necessary, and the second stage
was to determine the presence of delirium. The second stage consists of
four characteristics that are classified according to the assessment.
Characteristic 1 assesses acute change or fluctuations in mental status,
characteristic 2 assesses inattention, characteristic 3 assesses changes in
the consciousness level, and characteristic 4 assesses disorganized
thinking. Among the 10 cases, two cases confirmed whether it was
necessary to assess the delirium, two cases confirmed whether it was
possible to assess characteristic 1, two cases confirmed whether char­
acteristic 2 can be assessed, two cases verified whether characteristic 3
can be assessed, and two cases verified whether characteristic 4 can be
assessed. When each case was correctly evaluated, it was regarded as a
correct answer and was awarded 1 point, whereas a wrong answer was
awarded 0 points. The overall score ranged from 0 (lowest) to 10
(highest). A higher score represents higher delirium assessment accu­
racy. In this study, the reliability (KR-20) was 0.61.
The delirium accuracy assessment tool was verified for content and
user validity. The expert group comprised one nursing professor, one
intensive care specialist, one critical care physician, and four nurses
working in the ICU with more than 10 years of work experience. Expert
validity evaluated the content validity index on a 4-point Likert scale
and all 10 cases had values of more than 0.78 of the content validity
index scores. User validity was commissioned to five nurses in an ICU to
check whether the explanations of the cases were difficult to understand,
while resolving these problems.
2.4.3. Intervention
The aim of case-based CAM-ICU education was to improve delirium
knowledge and delirium assessment accuracy of ICU nurses. Case-based
education is more effective than classroom training (Devlin et al., 2008;
Gesin et al., 2012); therefore, we included lectures and assessment ed­
ucation. The lecture focused on delirium and the CAM-ICU tool, whereas
assessment education focused on the application of the CAM-ICU tool
using scenario-based cases and standardized patients.
2.4.3.1. Lecture on delirium and CAM-ICU tool. The lecture highlighted
the causes, symptoms, assessment, prevention, and treatment of
delirium, and use of the CAM-ICU tools. Educational materials were
drafted by researchers based on the literature (American Psychiatric
Association [APA], 2013; Ely et al., 2004). The materials were presented
to and received opinions from seven experts, comprising one nursing
professor, one intensive care specialist, one critical care physician, and
four nurses working in the ICU with more than 10 years of experience
caring for patients with delirium. Additionally, five nurses working in an
ICU were commissioned to check whether the contents of the materials
were difficult to understand.
2.4.3.2. Delirium assessment education using standardized patients based
on three cases. Delirium assessment education using standardized pa­
tients comprised three cases. The contents of each case consisted of the
patient's visit history, current situation, patient's condition, expected
behavior, and triggers by referring to the simulation case (Song, 2015).
The contents were reviewed by seven experts—a nursing professor, an
intensive care specialist, and five nurses with more than 10 years of
experience caring for patients with delirium (Table 1).
2.4.3.3. Standard patient's preparation. One standardized patient un­
derwent four role-based training sessions from September 1 to 20, 2017.
The standardized patient was placed in an ICU, lying on a bed, with an
electrocardiogram, oxygen saturator, and an automatic blood pressure
monitor. The central venous line was attached to the body, and an
infusion pump was used to make the actual drug appear for injection. In
cases 1 and 2, the patient had bitten the endotracheal intubation tube,
and the ventilator lines were connected. In case 2, the thoracic tube was
attached to the standardized patient's body to ensure it looks as real as
possible (Fig. 1).
2.4.3.4. Pilot application of a case-based CAM-ICU education session. The
pilot application of the education was performed on September 30,
2017, with six nurses in the ICU in a seminar room on the 3rd floor of the
hospital where this study was conducted. The place was large enough to

Table 1
Delirium assessment education.
Education Case 1 Case 2 Case 3

Contents Goal To know whether To know whether delirium evaluation is needed (stage 1) To know whether delirium evaluation is needed (stage 1)
delirium evaluation is Be able to evaluate acute changes or fluctuating of mental Be able to evaluate acute changes or fluctuating of mental
needed (stage 1) status and inattention, altered level of consciousness, and status and inattention, altered level of consciousness, and
disorganized thinking step-by-step (characteristics 1–4 in disorganized thinking step-by-step (characteristics 1–4 in
stage 2). stage 2).
Scenario RASS score is − 4(~ The RASS score was − 4, need for delirium evaluation RASS score was 0, need for delirium evaluation
progress − 5), no need for → Characteristic 1: As a result of assessing whether there → Characteristic 1: Due to assessing whether there was a
delirium evaluation was a change in mental state within 24 h or if there was an change in mental state within 24 h or if there was an acute
acute change. It progressed to evaluate inattention change. it progressed to evaluate inattention evaluation
→ Characteristic 2: As a result of evaluating the wrong → Characteristic 2: Due to evaluating the wrong number by
answers by presenting 10 numbers or pictures, it is judged presenting 10 numbers or pictures, the wrong answers were
that there was no delirium because the wrong number was more than 3. It progressed to evaluate the altered level of
0 to 2 consciousness.
→ Characteristic 3: Due to evaluating the level of
consciousness with a RASS score, the RASS score was 0. It
progressed to evaluate disorganized thinking.
→ Characteristic 4: Due to evaluating 4 questions and 1
performance, 2 or more answers were wrong. It was judged
to be delirium.
Standard Diagnosis Peritonitis Multiple sternum fractures Pneumonia
patients Current Stable vital signs High blood pressure Stable vital signs
status RASS Score: Tachycardia ∙RASS Score: 0
− 4 (~ − 5) Tachypnoea Nasal oxygen therapy
Intubation status RASS Score: No special appeal
Applying ventilation − 4 (+1 ~ +4) Look helpless
Movement is observed Intubation status
in strong pain stimuli Applying ventilation
Moving the limbs
Looking anxious

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Y.-N. Kim and D.-H. Kim Nurse Education Today 103 (2021) 104954

Table 2
Assessed for eligibility (n=122)
Homogeneity test on subject's general characteristics, delirium knowledge, and
delirium assessment accuracy.
(N = 122)
Allocated to experimental group (n=61) Allocated to control group (n=61)
- Took a case-based CAM-ICU - Did not take a case-based CAM- Characteristics Category Experimental Control χ2 /
education ICU education
Group (n = Group Za(p)
61) (n = 61)
n(%)/M ± SD n(%)/M
Follow-up was maintained Follow-up was maintained ± SD

Gender Male 4 (6.6) 1(1.6) 1.877

Female 57 (93.4) 60(98.4) (0.171)
Age(years old) >25 13(21.3) 10(16.4) 0.426
Analyzed (n=61) Analyzed (n=61) 25–29 35(57.4) 38(62.3) (0.671)
≥30 13(21.3) 13(21.3)
Education Diploma 5(8.2) 5(8.2) 0.538
Fig. 1. Flow diagram of the current study. Bachelor 51(83.6) 53(86.9) (0.764)
degree
Master 5(8.2) 3(4.9)
educate 10–15 people, and the session lasted 90 min. After the pilot degree or
study, the standardized patient was retrained to maintain the state more
suggested when the subject expressed unexpected behavior. Working career (year) >1 7(11.5) 4(6.5) 1.483
1 ~ <4 36(59.0) 30(49.2) (0.141)
4 ~ <7 7(11.5) 13(21.3)
2.4.3.5. The intervention. The case-based CAM-ICU education was ≥7 11(18.0) 14(23.0)
conducted in one session: 20 min of lecture, 60 min for a session on case- Delirium related Yes 39(63.9) 35(57.3) 0.550
based delirium assessment, and 10 min for questions and answers. education during last
Participants were divided into five groups of 10–12 nurses per group. year
No 22(36.1) 26(42.7) (0.578)
The lecture was conducted in a seminar room using handouts and
Delirium knowledge 31.75 ± 4.27 31.13 ± − 1.552
PowerPoint presentations prepared by one of the research team mem­ total 3.64 (0.121)
bers as study materials. After the lecture, nurses could ask questions Cause 9.10 ± 1.55 8.85 ± − 1.380
about the contents that required further explanation. 1.47 (0.168)
Delirium assessment education using standardized patients was Symptom 10.41 ± 1.97 10.33 ± − 0.521
2.00 (0.603)
conducted after the lecture. The case evaluation sheet was distributed to Management 12.25 ± 2.16 11.95 ± − 1.219
the nurses, and one nurse was invited to volunteer to conduct a delirium 2.00 (0.223)
assessment for the standardized patient. Other nurses were asked to Delirium assessment accuracy 2.89 ± 1.61 2.92 ± − 0.016
complete the case evaluation sheet, whereas the nurse volunteer con­ 1.94 (0.988)
ducted the delirium assessment for the standardized patient using the a
Mann-Whitney U test.
CAM-ICU tool. In the process of deriving delirium assessment, nurses
interpreted the meaning of the response from the standardized patient. 3.2. The effect of CAM-ICU education on delirium knowledge and
After completing one case, nurses were provided with some time to re­ delirium assessment accuracy
view their own case evaluation sheets. The nurses asked questions if they
required further explanation regarding the case before moving on to the The average score of delirium knowledge was changed from 31.75 ±
next case. The remaining cases were assessed in a similar method. After 4.27 points to 41.98 ± 2.17 points after intervention in the experimental
completing the lectures and case-based delirium assessment training, a group, whereas the score was changed from 31.13 ± 3.64 points to
Q&A session was conducted. 31.15 ± 3.54 points in the control group (Z = − 9.903, p < .001). Pre-and
post-test differences were noted in the subcategories of delirium
2.5. Data analysis knowledge between the two groups: cause-related knowledge (Z =
− 3.650, p < .001), symptom-related knowledge (Z = − 10.039, p <
Data were analyzed using the Statistical Package for the Social Sci­ .001), and management-related knowledge (Z = − 7.556, p < .001). In
ences (version 22.0; IBM Co., Armonk, NY, USA). The homogeneity of the experimental group, the cause-related knowledge of the group
the general characteristics of the experimental and control groups were increased from 9.10 ± 1.55 points before the intervention to 9.77 ± 0.56
analyzed using the χ2-test. The homogeneity test of delirium knowledge points after the intervention (Z = − 3.672, p < .001). Symptom-related
and delirium assessment accuracy of the two groups was analyzed using knowledge of the experimental group increased from 10.41 ± 1.97
the Mann-Whitney U test because it did not satisfy the normal distri­ points before the intervention to 18.15 ± 1.36 points after the inter­
bution. The pre- and post-test differences in delirium knowledge and vention (Z = − 6.810, p < .001), whereas management-related knowl­
delirium assessment accuracy between the two groups and within each edge of the experimental group increased from 12.25 ± 2.16 points to
group were also analyzed using the Mann-Whitney U test and the Wil­ 14.07 ± 1.01 points (Z = − 5.700, p < .001).
coxon signed-rank test. Significant difference was noted in the delirium accuracy scores
between the two groups (Z = − 9.668, p < .001) (Table 3). The delirium
3. Results accuracy scores in the experimental group changed from 2.89 ± 1.61
before the intervention to 8.11 ± 1.23 after the intervention (Z =
3.1. Homogeneity test on the general characteristics, delirium knowledge, − 6.709, p < .001); whereas in the control group, they changed from
and delirium assessment accuracy of participants 2.92 ± 1.94 points pre-intervention to 3.05 ± 2.99 points post-
intervention (Z = − 2.309, p = .021). Comparing the stages, the pre-
There was no statistically significant difference between the experi­ education score in the first stage, wherein it was determined whether
mental and control groups (Table 2). the delirium assessment was required, increased from 7.89 ± 1.16 to
10.00 ± 0.00 after the intervention (Z = − 6.576, p < .001). Stage 2
comprises four characteristics. The pre-education score of characteristic

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Y.-N. Kim and D.-H. Kim Nurse Education Today 103 (2021) 104954

Table 3
The effect of CAM-ICU education on delirium knowledge and delirium assessment accuracy.
(N = 122)

Group Pre Post Post-Pre Difference Difference

M ± SD M ± SD M ± SD Post-Pre within a groupa Post-Pre between the groupsb
Z (p) Z(P)

Delirium knowledge total Exp. 31.75 ± 4.27 41.98 ± 2.17 10.23 ± 3.94 − 6.801(<0.001) − 9.903(<0.001)
Con. 31.13 ± 3.64 31.15 ± 3.54 0.02 ± 0.47 − 0.277(0.157)
Cause Exp. 9.10 ± 1.55 9.77 ± 0.56 0.67 ± 1.35 − 3.672(<0.001) − 3.650(<0.001)
Con. 8.85 ± 1.47 8.89 ± 1.38 0.03 ± 0.18 − 1.414(0.180)
Symptom Exp. 10.41 ± 1.97 18.15 ± 1.36 7.74 ± 2.20 − 6.810(<0.001) − 10.039(<0.001)
Con. 10.33 ± 2.00 10.38 ± 1.99 0.05 ± 0.28 − 1.342(0.102)
Management Exp. 12.25 ± 2.16 14.07 ± 1.01 1.87 ± 1.94 − 5.700(<0.001) − 7.556(<0.001)
Con. 11.95 ± 2.00 11.89 ± 1.95 − 0.07 ± 0.31 − 1.633(0.782)
Delirium assessment accuracy Exp. 2.89 ± 1.61 8.11 ± 1.23 5.23 ± 1.89 − 6.709(<0.001) − 9.668(<0.001)
Con. 2.92 ± 1.94 3.05 ± 2.99 0.10 ± 0.40 2.309(0.021)

Exp. = Experimental group, Con. = Control group.

a
Wilcoxon signed rank test.
b
Mann-Whitney U test.

1, acute change or fluctuations in mental assessment, increased from be improved through education; therefore, nurses must be provided
7.86 ± 0.95 to 9.95 ± 0.22 after the intervention (Z = − 6.824, p < .001). with education to ensure high delirium knowledge. To improve delirium
The pre-education score of characteristic 2, inattention assessment, knowledge, this study used a lecture method accompanied by a Pow­
increased from 5.56 ± 1.74 points to 9.07 ± 0.77 after the intervention erPoint presentation, with a small group of nurses. Studies have shown
(Z = − 6.639, p < .001). The pre-education score of characteristic 3, an the effectiveness of the use of lectures and PowerPoint presentations
altered level of consciousness, increased from 4.44 ± 1.49 to 8.69 ± 0.99 (Cho, 2011; Gesin et al., 2012; Park and Park, 2013; Speed, 2015), the
after the intervention (Z = − 6.650, p < .001). The pre-education score of Internet (Detroyer et al., 2016; Van De Steeg et al., 2015), patient sce­
characteristic 4, disorganized thinking assessment, increased from 6.02 narios, role-playing, discussion, lectures, and self-directed study (Kang
± 1.83 to 9.52 ± 0.62 after the intervention (Z = − 6.595, p < .001) et al., 2017), videos or case-study analyses using CAM-ICU screenings,
(Table 4). patient bedside instruction, and return demonstration of performance of
the CAM-ICU delirium screening (Blevins and DeGennaro, 2018), or
4. Discussion classroom learning, demonstrations, and hands-on practice in the CAM-
ICU (2018). The lecture method provides the advantage of direct feed­
To ensure early detection of delirium and provide adequate care, it is back during the Q&A session between the participants and educators. In
necessary to know the causes and symptoms of delirium and ensure this study, we asked participants about the program content and diffi­
delirium assessment accuracy based on this knowledge. To this end, this culties related to using the CAM-ICU in clinical practice. On the other
study developed a case-based CAM-ICU education and applied the hand, the lecture conducted using the Internet provided the advantage
developed education to nurses working in ICUs to test its effectiveness. of having no restrictions, in terms of time and place, and the possibility
As a result of the intervention developed in this study, the experi­ of repeating the lesson when required. Therefore, the effects of educa­
mental group that participated in the case-based CAM-ICU education tion can be further enhanced if face-to-face and Internet-based lectures
noted significant improvement in their delirium knowledge, compared are combined in future educational programs.
with the control group. This result is consistent with that of previous The experimental group that participated in the case-based CAM-ICU
studies (Blevins and DeGennaro, 2018; Cho, 2011; Detroyer et al., 2016; education in this study noted significant improvements in their delirium
Gesin et al., 2012; Kang et al., 2017; Park and Park, 2013; Ramoo et al., assessment accuracy, compared with the control group. This result is
2018; Speed, 2015; Van De Steeg et al., 2015). Delirium knowledge can consistent with that of previous studies (Blevins and DeGennaro, 2018;
Devlin et al., 2008; Gesin et al., 2012) that led to improved scores for
delirium assessment accuracy after the educational program. Delirium
Table 4
assessment accuracy can be improved through education; therefore,
The effect of CAM-ICU education on delirium assessment accuracy in experi­
mental group. delirium education for nurses must be implemented. To improve the
accuracy of delirium assessment, this study developed a case study and
(N = 61)
training using standardized patients. In previous studies (Blevins and
Subcategory Pre Post Post-Pre Difference DeGennaro, 2018; Devlin et al., 2008; Gesin et al., 2012), participants
M ± SD M ± SD M ± SD Post-Prea
were trained for the use of delirium assessment tools. Although it is not
Z (p)
solely focused on delirium education, case-based education improves
Stage 1 7.89 ± 10.00 ± 2.11 ± − 6.576 the ability to adapt to clinical practice by improving nursing perfor­
1.16 0.00 1.16 (<0.001)
Stage 2
mance (Jeong and Park, 2015), compared with lecture-based education.
Characteristic 1 7.86 ± 9.95 ± 0.22 2.11 ± − 6.824 Case-based training can be used to plan various educational programs to
0.95 0.93 (<0.001) improve performance.
Characteristic 2 5.56 ± 9.07 ± 0.77 3.51 ± − 6.639 In this study, the delirium assessment accuracy significantly
1.74 1.72 (<0.001)
improved at all stages. The assessment accuracy score for change in the
Characteristic 3 4.44 ± 8.69 ± 0.99 4.25 ± − 6.650
1.49 1.97 (<0.001) level of consciousness was the lowest at 100 and 44 points before edu­
Characteristic 4 6.02 ± 9.52 ± 0.62 3.51 ± − 6.595 cation. Based on the RASS score, changes in the level of consciousness
1.83 1.84 (<0.001) should be evaluated to determine whether the assessment for the next
Characteristics 1 assess acute change or fluctuating of mental status, charac­ step is necessary. Inattention had the second lowest assessment accuracy
teristics 2 assess inattention, characteristics 3 assess altered level of conscious­ score. Inattention should be evaluated to determine whether assessment
ness, and characteristics 4 assess disorganized thinking. for the next step is necessary. Participants evaluated the wrong answers
a
Wilcoxon signed rank test. but could not determine whether inattention was present. Therefore,

5
Y.-N. Kim and D.-H. Kim
participants could evaluate the RASS score or the wrong number, but
lacked the ability to determine the change implied in each evaluation
result. The progress to the next stage was based on the evaluation re­
sults, which were sufficiently explained during the education
intervention.
The current study featured some limitations. First, the groups were
not randomized to prevent the spreading effect. The study setting was
limited to a hospital in a particular area; therefore, the study findings
may not be generalizable. Nevertheless, this study developed a case-
based CAM-ICU educational program for delirium assessment at a
time when intensive care nurses were not trained in Korea and applied
their knowledge using standardized patients. A significant need has been
noted to improve delirium knowledge and delirium assessment accu­
racy. The case-based CAM-ICU educational program developed in this
study can be used to further develop the knowledge of intensive care
nurses. Future research can focus on the sustainability of the developed
case-based CAM-ICU educational program.
5. Conclusion
Delirium assessment is based on the judgment of symptoms; there­
fore, delirium knowledge is crucial for ensuring accurate assessments. In
the current study as well as previous studies in this field, the “delirium
knowledge” score was low, particularly for symptom-related knowledge.
This resulted in a delay in diagnosis, because delirium symptoms were
not observed. Therefore, education on delirium knowledge, an assess­
ment tool, and training for applying the tool, was required to improve
delirium assessment accuracy. The study results confirmed that a case-
based CAM-ICU educational program served as an effective interven­
tion for improving delirium knowledge and delirium assessment accu­
racy in ICU nurses. This study was conducted at a hospital and can be
used directly for nurse education. Furthermore, the study results
contribute to the development of clinical nursing research. Based on the
study results, various cases can be developed for the education of
intensive care nurses.
CRediT authorship contribution statement
YN and DH designed the study. YN performed the statistical analysis.
YN and DH drafted and critically revised the manuscript. All authors
read and approved the final manuscript.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
None of the authors have any personal or financial conflicts of in­
terest to declare.
Acknowledgements
We would like to thank the nurses who participated in the study.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.nedt.2021.104954.
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